Information for Foster Parents - Part B, CFS-872B



Information for Out-Of-Home Care ProvidersPart BUse of form: The information contained in this form must be provided to the out-of-home care provider before the prospective out-of-home care provider agrees to placement of the child / youth or no later than seven days after the child / youth is placed with the out-of-home care provider. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes].I.GENERAL INFORMATIONDate Last Reviewed/Filled Out (mm/dd/yyyy)Out-of-Home Care Provider FORMTEXT ????? FORMTEXT ?????Child / Youth InformationFull Name (Legal)Birth Date (mm/dd/yyyy)Social Security Number FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Chosen NamePronounsGender FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Child / Youth Identifies as: FORMTEXT ?????Race(s)Ethnicity FORMTEXT ????? FORMTEXT ?????II.PLACEMENT REASON(S) FORMCHECKBOX Child abuse or neglect (CAN) FORMCHECKBOX Physical abuse FORMCHECKBOX Sexual abuse FORMCHECKBOX Emotional abuse FORMCHECKBOX Neglect FORMCHECKBOX Youth Justice FORMCHECKBOX Developmental needs FORMCHECKBOX Medical needs FORMCHECKBOX Substance use – parent FORMCHECKBOX Substance use – child / youth FORMCHECKBOX Emotional needs FORMCHECKBOX Behavioral needs FORMCHECKBOX Life functioning needs FORMCHECKBOX Death, illness, or incarceration of primary caregiver FORMCHECKBOX Yes FORMCHECKBOX NoCHIPS, other than CANType of Petition: CHIPS / JIPS / Delinquency FORMTEXT ?????Nature of Offense(s) FORMTEXT ?????Placement is: FORMCHECKBOX Voluntary FORMCHECKBOX Court ordered FORMCHECKBOX Temporary Physical CustodyOther Placement Reasons – Specify. FORMTEXT ?????ALL ABOUT METhis section should be completed by or with the child or youth.My strengths are: FORMTEXT ?????My goals are: FORMTEXT ?????What I would like support with: FORMTEXT ?????I think it’s important that you know the following about me: FORMTEXT ?????III.SIGNIFICANT CONTACTSGuardian ad litem (GAL) / Legal CounselFull NameRelationship FORMTEXT ????? FORMTEXT ?????Address (Street, City, State, Zip Code)Telephone NumberEmail FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other Individuals / ContactsFull NameRelationship FORMTEXT ????? FORMTEXT ?????Type of ContactTelephone NumberEmail FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????IV.CHILD / YOUTH AND FAMILY STRENGTHS FORMTEXT ?????V.PLACEMENT HISTORY AND PERMANENCE GOAL(S)A.Previous Placement (If there is no court order prohibiting release of name of previous out-of-home care provider(s))Placement Type(FH, GH, RCC, hospital, etc.)Full NamePlacement DatesFrom(mm/dd/yyyy)To(mm/dd/yyyy) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????B.Permanency Goal(s) – FORMCHECKBOX Permanence Goal Yet to be DeterminedPermanence GoalConcurrent Goal FORMCHECKBOX Reunification FORMCHECKBOX Reunification FORMCHECKBOX Guardianship FORMCHECKBOX Guardianship FORMCHECKBOX Adoption FORMCHECKBOX Adoption FORMCHECKBOX Placement with a fit and willing relative* FORMCHECKBOX Placement with a fit and willing relative* FORMCHECKBOX Other Permanent Planned Living Arrangement* FORMCHECKBOX Other Permanent Planned Living Arrangement** Not legal permanenceVI.TRAUMA HISTORY (Consider information from over the lifetime)A.Sexual Abuse History – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Child / Youth is a victim of sex or human trafficking FORMCHECKBOX Any involvement of the child / youth as a victim in sexual intercourse, sexual contact, sex trafficking, sexual exploitation of a child / youth, causing a child / youth to view or listen to sexual activity (s. 948.055) FORMCHECKBOX OtherSpecify (If yes explain circumstances: considering frequency, familial support, and Maltreater’s relationship to child / youth) FORMTEXT ?????B.Trauma History – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Physical abuse FORMCHECKBOX Emotional abuse FORMCHECKBOX Neglect FORMCHECKBOX Child / youth has witnessed family or community violence FORMCHECKBOX Victim of criminal activity or witnessed the victimization of a family or friend FORMCHECKBOX OtherSpecify (If yes explain circumstances) FORMTEXT ?????C.Adjustment to Trauma Considerations – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Problems with affect regulation (e.g., exaggerated emotional response, experiences episodes of dissociation) FORMCHECKBOX Re-experiences the trauma (e.g., sleep disturbance, nightmares) FORMCHECKBOX Increased arousal FORMCHECKBOX Adjustment problems (e.g., PTSD, flashbacks, nightmares, anxiety) FORMCHECKBOX Experiences episodes of dissociation (e.g., avoids thoughts / feelings associated with the trauma, unable to recall a specific event, etc.) FORMCHECKBOX Difficulty with a numbing response (e.g., flat emotional state, detached) FORMCHECKBOX Traumatic grief due to death or the separation from caregiver FORMCHECKBOX Experiences intrusive thoughts FORMCHECKBOX OtherSpecify (If yes explain circumstances) FORMTEXT ?????VII.SCHOOL / CHILD CARE (Consider information from the current or most recent school year)Child / youth is Currently Enrolled in School – FORMCHECKBOX Yes FORMCHECKBOX NoDescribe current academic performance. Include grade level, special achievements, and current educational difficulty(s). Include the date and source of your information: FORMTEXT ?????Consider the following (Check all that apply) FORMCHECKBOX Extra time spent with child / youth on required school activities (e.g., homework) FORMCHECKBOX Difficulty getting along with teacher or peers FORMCHECKBOX Frequent suspensions or expulsions FORMCHECKBOX Attendance / Truancy concerns, unrelated to school suspensions FORMCHECKBOX Disruptions at school or day care FORMCHECKBOX School / child care does not meet the needs of the child / youthSpecify (If yes explain circumstances) FORMTEXT ?????VIII.LIFE FUNCTIONING (Consider information from the six months prior to completion of this form)Developmental Care Considerations – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Significant delays in cognitive functioning or possible fine or gross motor skill delay FORMCHECKBOX Has physical or developmental care needs beyond what is typical of the child’s / youth’s age FORMCHECKBOX Difficulty understanding simple routines or simple tasks (possibly requires assistance or verbal prompting to complete self-care tasks) FORMCHECKBOX OtherSpecify (If yes explain circumstances) FORMTEXT ?????Social Functioning Considerations – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Social relationships with same age peers or adults outside of school FORMCHECKBOX Relationships with parents and / or siblings (e.g., arguing, difficulty in maintaining a positive relationship) FORMCHECKBOX Making and maintaining friendships FORMCHECKBOX Ability to communicate is not developmentally on target for their age (e.g., unable to express wants and / or needs, language comprehension challenges or requires supportive communication devices etc.) FORMCHECKBOX OtherSpecify (If yes explain circumstances) FORMTEXT ?????Other Life Functioning Considerations – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX No engagement or interest in recreational activities FORMCHECKBOX Needs additional support to develop independent living skills (e.g., cooking and / or cleaning, money management, hygiene, etc.) FORMCHECKBOX OtherSpecify (If yes explain circumstances) FORMTEXT ?????IX.MEDICAL INFORMATION (Consider information from over the lifetime)Mental Health Considerations – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Medical trauma considerations relevant for providing care to child / youth FORMCHECKBOX History of mental health needs or diagnosis in family FORMCHECKBOX Psychiatric diagnosis (e.g., Psychosis, Major Depressive Disorder, Post Traumatic Stress Disorder, etc.) FORMCHECKBOX Extreme fears or phobias FORMCHECKBOX Anxiety FORMCHECKBOX Suicidal Risk FORMCHECKBOX Other risk of self-harm (e.g. self-injurious) FORMCHECKBOX Exploited FORMCHECKBOX OtherSpecify (If yes explain circumstances) FORMTEXT ?????Medical Illness or Diagnosis – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Diabetes FORMCHECKBOX Seizure disorder, epilepsy FORMCHECKBOX Cerebral Palsy, Muscular Dystrophy FORMCHECKBOX Down’s Syndrome FORMCHECKBOX Autism Spectrum Disorder FORMCHECKBOX Cancer, leukemia, or other malignancy FORMCHECKBOX OtherSpecify (If yes explain circumstances including: current status of illness / diagnosis, what medical treatment / intervention it requires, whether or not the condition is a lifelong medical condition or is life threatening, and what social emotional needs the child / youth has in relation to the medical condition): FORMTEXT ?????X.HEALTH CONCERNS OR SYMPTOMSA.Brain or head conditions – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Serious head injury or loss of consciousness FORMCHECKBOX Headaches, migraines, dizziness, coordination, or balance challenges FORMCHECKBOX OtherSpecify (If yes explain injury or concern): FORMTEXT ?????B.Heart and lung concerns – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Heart trouble or murmur, chest pain, irregular heartbeat FORMCHECKBOX Wheezing, bronchitis FORMCHECKBOX OtherSpecify (If yes explain injury or concern): FORMTEXT ?????C.Skin conditions – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Lice, scabies, worms FORMCHECKBOX Chronic diaper rash, impetigo FORMCHECKBOX Treatment for skin trouble, rashes, hives, breaking out, acne FORMCHECKBOX Eczema FORMCHECKBOX OtherSpecify (If yes explain injury or concern): FORMTEXT ?????D.Eye, ear, nose, throat, or dental problems – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Trouble swallowing, speaking, persistent hoarseness FORMCHECKBOX Chronic or severe ear or sinus infections FORMCHECKBOX Severe or painful dental problems FORMCHECKBOX Blindness, blurred, or double vision FORMCHECKBOX Hearing problems, ringing ears, discharge / infection, tubes FORMCHECKBOX Sensory disorder / diagnosis FORMCHECKBOX OtherSpecify (If yes explain injury or concern): FORMTEXT ?????E.Systemic conditions – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Urinary, prostate, gall bladder, kidney problems FORMCHECKBOX Reflux, choking, heartburn, ulcers FORMCHECKBOX Constipation, diarrhea, blood in stool FORMCHECKBOX Incontinent, encopretic FORMCHECKBOX OtherSpecify (If yes explain injury or concern): FORMTEXT ?????F.Risk factors – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Low birth weight FORMCHECKBOX Lack of prenatal care FORMCHECKBOX Born premature or overdue FORMCHECKBOX Complications at birth FORMCHECKBOX In utero / fetal exposure to alcohol and / or drugs FORMCHECKBOX OtherSpecify (If yes explain injury or concern): FORMTEXT ?????XI.MEDICAL APPOINTMENTS AND TREATMENT CONSIDERATIONS – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Frequent mental health appointments, doctor visits, or hospitalizations FORMCHECKBOX Relevant Medical Tests (Child /youth has had medical tests provider should be aware of) FORMCHECKBOX CAT scan FORMCHECKBOX EEG FORMCHECKBOX MRI FORMCHECKBOX TB skin test FORMCHECKBOX FORMCHECKBOX Chest x-ray FORMCHECKBOX EKG FORMCHECKBOX FORMCHECKBOX Pap test FORMCHECKBOX Other FORMCHECKBOX Recent hospitalization(s) FORMCHECKBOX Has the child/youth received mental, behavioral, or emotional health services in the past? FORMCHECKBOX Autism Spectrum Disorder FORMCHECKBOX Significant development delay FORMCHECKBOX Cognitive disabilities FORMCHECKBOX Specific learning disabilities FORMCHECKBOX FORMCHECKBOX Emotional behavioral disabilities FORMCHECKBOX Speech / language impairment FORMCHECKBOX Other FORMCHECKBOX OtherSpecify (If yes explain circumstances) FORMTEXT ?????XII.CULTURAL CONSIDERATIONS (Consider information from over the lifetime)Cultural Identity FORMCHECKBOX Child / youth and / or family is connected to their culture practices FORMCHECKBOX Provider accommodations needed so that child / youth can take part in cultural practices FORMCHECKBOX Child / youth and / or family would like to, or needs assistance, making / maintaining child’s / youth’s connections to others who share their cultural identity FORMCHECKBOX Child / youth and / or family would like the child / youth to participate in, or needs support, to engage in cultural practices, rituals, or ceremonies FORMCHECKBOX OtherDescribe child / youth and family’s cultural connections, desires, and ongoing needs to establish or maintain cultural identity and connection: FORMTEXT ?????XIII.EMOTIONAL NEEDS (Consider information from the previous six months prior to completion of the document, unless more historical information is necessary to disclose to protect the child / youth or others)Attachment Considerations – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Avoids emotional situations and personal relationships FORMCHECKBOX Child / youth exhibits attachment difficulties with caregiver, teacher, or other (e.g., over or under reacts to separation / family interactions, difficulty maintaining attachment) FORMCHECKBOX OtherSpecify (If yes explain circumstances) FORMTEXT ?????Attention Considerations – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Extreme hyperactive and impulsive behaviors FORMCHECKBOX Has difficulty focusing or sustaining attention in home environment FORMCHECKBOX Needs structured behavior management, fails to respond to limit / rule setting or discipline (e.g., intentional misbehavior) FORMCHECKBOX OtherSpecify (If yes explain circumstances) FORMTEXT ?????Other Emotional Considerations – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Difficult to soothe or console by self or others FORMCHECKBOX Displays emotions that could be deemed inappropriate to the situation FORMCHECKBOX Frequent temper tantrums or rage, atypical for the child’s / youth’s age / development FORMCHECKBOX Takes unusual risks with personal safety (e.g., involvement in activities that are harmful to the child’s / youth’s physical, mental or moral well-being, lack of boundaries with strangers, lack of fear, etc.) FORMCHECKBOX OtherSpecify (If yes explain circumstances) FORMTEXT ?????XIV.BEHAVIORAL NEEDS (Consider information from the previous six months prior to completion of the document, unless more historical information is necessary to disclose to protect the child / youth or others)Dietary Needs or Considerations – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Gorges / binges or hoards food FORMCHECKBOX Eats non-food items FORMCHECKBOX Eating disorder; if not formally diagnosed, may include indications of excessive preoccupation with food, weight, or body image, dramatic weight gain or loss FORMCHECKBOX OtherSpecify (If yes explain circumstances) FORMTEXT ?????Substance Use or Abuse – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Tobacco FORMCHECKBOX Alcohol FORMCHECKBOX Drugs FORMCHECKBOX Solvents FORMCHECKBOX Marijuana FORMCHECKBOX OtherSpecify (If yes explain circumstances, frequency of use, how child / youth gets access, current treatment needs, etc.): FORMTEXT ?????Sexual Development and / or Behavior Considerations – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Any involvement of the child / youth as a perpetrator in sexual intercourse, sexual contact, sexual exploitation of a child, causing a child to view or listen to sexual activity (s. 948.055) FORMCHECKBOX Sexual behaviors, displays overt sexual gestures, language, or dress FORMCHECKBOX Sexually active FORMCHECKBOX Use of birth control, medication, or other birth control methods FORMCHECKBOX Anxiety associated with sexual identity FORMCHECKBOX High-risk sexual experiences (e.g., multiple partners, older partners, victim of child sex trafficking) FORMCHECKBOX OtherSpecify (If yes explain circumstances) FORMTEXT ?????Violence or Aggression Considerations – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Lack of concern for others, lack of remorse or empathy FORMCHECKBOX Gang affiliation FORMCHECKBOX Extreme destruction of property FORMCHECKBOX Physically threatening or assaultive FORMCHECKBOX Physically or sexually abusive or cruel to animals FORMCHECKBOX Bullies or instigates situations or fights FORMCHECKBOX Verbally aggressive FORMCHECKBOX Inappropriate use of weapons FORMCHECKBOX OtherSpecify (If yes explain circumstances) FORMTEXT ?????Youth Justice Involvement – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Involvement in the legal system (delinquency petition, Youth Justice referrals, Youth Justice county supervision, etc.) FORMCHECKBOX Was assigned victim restitution FORMCHECKBOX Child / youth has court orders / sanctions FORMCHECKBOX Behavior places community residents at risk of harm FORMCHECKBOX Influenced by parental behavior FORMCHECKBOX Factors in environment increase child / youth vulnerability to engage in delinquent behavior FORMCHECKBOX OtherSpecify (If yes explain circumstances) FORMTEXT ?????Runaway Behavior/History Considerations – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Runs frequently, or has run on multiple occasions FORMCHECKBOX Consistently runs to the same location, neighborhood, or community FORMCHECKBOX Runs to unsafe environments; likelihood of victimization is high FORMCHECKBOX Engages in delinquent and / or dangerous activities while on the run FORMCHECKBOX Others encourage or help youth to run FORMCHECKBOX OtherSpecify (If yes explain circumstances, describe the primary factors that have previously contributed to the child’s / youth’s missing episode, describe any plans or interventions that should be put in place to ensure the child’s / youth’s safety, well-being, and prevention of running in the future): FORMTEXT ?????Other Behavioral Considerations – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Engages in fire starting behavior FORMCHECKBOX Does not sleep through the night, including nightmares, sleepwalking FORMCHECKBOX Wets the bed FORMCHECKBOX Expresses thoughts or behaviors resulting in harm to self or others (e.g., death, weapons, fire, etc.) FORMCHECKBOX Behaviors such as habitual dishonesty or theft, beyond normal age-based expectations FORMCHECKBOX Behavioral regression FORMCHECKBOX OtherSpecify (If yes explain circumstances) FORMTEXT ?????XV.OUT-OF-HOME CARE PROVIDER QUALIFICATIONS OR NEEDS – FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Frequency and distance of transportation FORMCHECKBOX Frequency of family interaction visits FORMCHECKBOX Transportation to school of origin FORMCHECKBOX Involvement in medical or therapy appointments FORMCHECKBOX OtherSpecify (If yes explain circumstances) FORMTEXT ?????XVI.IMPORTANT DOCUMENTSThe placing agency has given the out-of-home care provider (s): (Check all that apply.) FORMCHECKBOX Court order FORMCHECKBOX MA card FORMCHECKBOX Immunization Record FORMCHECKBOX Foster Home Agreement / Relative Caregiver Agreement FORMCHECKBOX Voluntary Placement Agreement FORMCHECKBOX Education Passport FORMCHECKBOX Reasonable and Prudent Parenting Standard Brochure (DCF – P – 5105) FORMCHECKBOX Medical Discharge Instructions (if child / youth is being released from hospital to caregiver FORMCHECKBOX Summary of mental health treatment* FORMCHECKBOX Medical Services Consent FORMCHECKBOX Other – Specify: FORMTEXT ????? FORMCHECKBOX Other – Specify: FORMTEXT ?????*Summary is requested to ensure that materials can be interpreted by the out-of-home care provider(s). Primary source documents can be provided if useful for clarification. This form and the information included herein have been shared with the out-of-home care provider(s).XVII.PLAN FOR MANAGING CHALLENGING BEHAVIORS (Consider information from the previous six months prior to completion of the document to inform the plan, unless more historical information is necessary to best meet the needs of the child / youth)Describe any special skills or knowledge the out-of-home care provider will need to acquire to meet the needs of the child / youth and provide support and care to the child/youth in a safe manner. FORMTEXT ?????List the child’s / youth’s behaviors that may lead to health or safety concerns for the child / youth or others. FORMTEXT ?????Describe actions or situations that contribute to a child’s / youth’s struggles and how child / youth may present when they are in need of additional support. FORMTEXT ?????Describe interventions that have worked in the past in de-escalation. FORMTEXT ?????Describe the agency’s reporting requirements and debriefing procedures for emergency situations. FORMTEXT ?????XVIII.SIGNATURES FORMTEXT ????? FORMTEXT ?????SIGNATURE – Parent 1Date Signed FORMTEXT ????? FORMTEXT ?????SIGNATURE – Parent 2Date Signed FORMTEXT ????? FORMTEXT ?????SIGNATURE – YouthDate Signed FORMTEXT ????? FORMTEXT ?????SIGNATURE – Placing Child Welfare ProfessionalDate Signed FORMTEXT ????? FORMTEXT ?????SIGNATURE – Out-of-Home Care ProviderDate Signed FORMTEXT ????? FORMTEXT ?????SIGNATURE – Out-of-Home Care ProviderDate Signed ................
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